Kev siv dav dav​​ 

Can DHCS please clarify what it means that DHCS will begin conducting compliance reviews of Medi-Cal managed care plans’ (MCPs’) implementation of CLR one year after the go-live date of July 1, 2025? Does DHCS expect MCPs to be fully compliant with CLR by July 1, 2025?​​ 

DHCS tab tom muab MCPs lub sijhawm muaj txiaj ntsig rau kev tau txais CLR cov txheej txheem thiab cov txheej txheem hauv qhov chaw tom qab CLR txoj cai siv tau rau lub Xya Hli 1, 2025. Thaum DHCS cia siab tias MCPs yuav siv CLR los ntawm Lub Xya Hli 1, 2025, DHCS lees paub tias yuav xav tau sijhawm ntxiv los kho CLR kev ua haujlwm thiab kev siv cov kev cai xws li kev ceeb toom thiab taug qab cov txheej txheem, kev hloov kho tshiab, thiab kev ua haujlwm tom qab hnub mus nyob. Yog li ntawd, DHCS yuav pib soj ntsuam kom ua raws li lub Xya hli ntuj 1, 2026.​​ 

Taug qab cov tswvcuab xa mus​​ 

MCPs qee zaum tau txais cov ntaub ntawv nquag thiab muaj txiaj ntsig ntawm kev xa mus thiab kev koom tes ncaj qha los ntawm lawv cov neeg muab kev pab cuam Enhanced Care (ECM). Puas muaj peev xwm suav nrog lwm cov ntaub ntawv los ua kom tiav CLR taug qab cov cai rau kev hais txog cov lus thov ntxiv thiab ntsib cov ntaub ntawv?​​ 

MCPs tuaj yeem siv lwm cov ntaub ntawv los ntxiv CLR nrhiav qhov chaw uas tau teev tseg hauv cov lus qhia; Txawm li cas los xij, MCPs tsis tuaj yeem xav kom ECM/Community Supports Providers xa cov ntaub ntawv rau kev taug qab ntawm txoj kev uas tsis yog Cov Ntaub Ntawv Xa Rov Qab (RTF).​​ 

Will the DHCS confirm the MCP can close the loop as “Services Received” if the ECM or Community Supports provider confirms services are rendered or begun via data included on the RTF? The term billable service implies the MCP has received a claim which could take six months.​​ 

MCPs can close the loop of a CLR as “Services Received” once the Provider confirms services are rendered via the Reason for Referral Loop Closure data element in the RTF.​​ 

Yuav ua li cas CLR taug qab thiab ceeb toom yuav tsum siv rau cov chaw sobering?  Puas yog tus tswvcuab ceeb toom rau kev pabcuam 24-teev?​​ 

CLR cov kev cai yuav tsis siv rau Sobering Centers vim tias cov kev pabcuam feem ntau xa tuaj raws sijhawm, qhov ntev ntawm kev nyob qis dua 24 teev, thiab cov kev pabcuam feem ntau raug tso cai los ntawm kev rov qab los pab txhawb kev nkag mus rau lub sijhawm rau Kev Pabcuam Hauv Zej Zog.​​ 

Can DHCS clarify the intended use of the “Declined” Referral Status value by ECM and Community Supports Providers?​​ 

The standard CLR Referral Status values may apply across a range of services over time. Currently, DHCS anticipates that ECM and Community Supports service providers may enter a “Declined” Referral Status for any of the following reasons: the provider lacks capacity, the Member doesn’t live in their service area, or for other reasons. MCPs should work with their Network Providers and provide clear documented procedures to determine which reasons are permissible for denying a referral in accordance with ECM and Community Supports policies and how it should be notated in the Referral Status value. DHCS is not implying that MCPs should adopt new policies to allow Network Providers to deny referrals.​​ 

In the DHCS Addendum to the PHM Policy Guide: Closed-Loop Referral Implementation Guidance, Table 4: Referral Processing has “Servicing Provider Name” and “Servicing Provider Phone Number” listed. Can DHCS please clarify if this is the Member’s assigned lead care manager and their phone number?​​ 

The “Servicing Provider Name” and “Servicing Provider Phone Number” is the name and phone number of the entity (i.e., Servicing Provider) that receives the ECM or Community Support referral request from the MCP or the Referring Entity. For example, on pages 23-24 of CalAIM Data Guidance: Member-Level Information Sharing Between MCPs and ECM Providers Guidance, the information would be consistent with the “ECM Provider Name” and “ECM Provider Phone Number. The intent of the fields is to confirm the MCP has recorded contact information they can leverage to support the referral and service delivery for the Member for different Providers/Services to which CLR requirements apply.​​ 

Can DHCS explain the difference between “Servicing Provider Organization Name” & “Servicing Provider Name”?​​ 

The “Servicing Provider Organization Name” is the ECM Provider (i.e., organization name). “The Servicing Provider Name” is the ECM Lead Care Manager that is assigned to provide the ECM service (the person at the organization assigned to the member).​​ 

Qhov kev xav tau los qhia txog Kev Xa Mus Los Kaw qhov laj thawj nrog Cov Chaw Xa Khoom yuav tsum tau sib koom cov ntaub ntawv tiv thaiv kev noj qab haus huv (PHI) nrog cov chaw tsis muaj kev tiv thaiv yam tsis muaj kev tso cai los ntawm Tswv Cuab. MCPs ntseeg tias qhov kev xav tau no tsis ua raws li HIPAA thiab thov kom DHCS tshem tawm qhov yuav tsum tau ua.​​ 

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) permits covered entities, including MCPs, to use or disclose “protected health information” (PHI) for certain purposes, including treatment, payment, or health care operations (certain administrative, legal, financial, and quality improvement activities, including care coordination and case management), without patient authorization. Such disclosures may be made both to other covered entities (e.g., health care providers) and to non-covered entities (e.g., housing providers, community-based organizations (CBOs)), as long as the disclosures are for purposes of treatment, payment and health care operations.​​  

Referral Loop Closure Reason and Referral Loop Closure Date would both constitute PHI under HIPAA; as covered entities, MCPs are able to share that information with non-covered entities without individual authorization for purposes of treatment and care coordination. 45 CFR 164.506(c)(1) provides that covered entities may use and disclose PHI for their own treatment, payment and health care operations purposes.​​ 

DHCS puas tuaj yeem muab txoj kev hla kev rau kev sib cuam tshuam ntawm CLR cov xwm txheej tshiab thiab cov xwm txheej uas twb muaj lawm hauv RTF, thiab tshem tawm CLR cov cai tshiab los ntawm ECM RTF thiab siv cov xwm txheej ECM uas twb muaj lawm rau CLR taug qab? ECM RTF twb taug qab CLR los ntawm cov xwm txheej tsim, tab sis cov xwm txheej CLR tshiab tsis ua raws, tsim kom tsis muaj teeb meem. Tshem tawm lawv yuav txo qhov tsis meej pem thiab kev tswj hwm lub nra thaum tswj xyuas cov txheej txheem sib dhos.​​ 

DHCS tsis tuaj yeem ua raws li qhov kev thov kom tshem tawm Cov Kev Xa Mus Los hloov pauv, vim qhov no yog tus nqi tseem ceeb rau kev ua qauv CLR taug qab. Txawm li cas los xij, DHCS tab tom ua haujlwm rau cov kev daws teeb meem, thaum txiav txim siab MCP cov lus tawm tswv yim txog qhov cuam tshuam ntawm kev tshem tawm cov teb uas twb muaj lawm.​​   

DHCS puas tuaj yeem muab kev qhia meej txog qhov sib txawv ntawm qhov kev xa mus rau 1 - Txais thiab 3-Tsav, vim nws tsis paub meej hauv ECM kev ua haujlwm tam sim no yuav ua li cas sib txawv ntawm lawv.​​ 

“Pending” is the default Referral Status for a referral made to an ECM or Community Supports Provider on the MIF when the Provider has not yet viewed the referral and confirmed they have capacity to serve the Member and intend to initiate outreach. “Accepted” is indicated once the Provider reviews the referral and intends to outreach the Member but has not yet done so. Please see Table 11 of the CLR Implementation Guidance for additional description of the values for the Referral Status variable.​​ 

MCPs txhawj xeeb tias DHCS tso cai rau cov neeg muab kev pab cuam txo qis kev xa mus uas tuaj yeem ua rau muaj kev xaiv los txais cov Tswv Cuab thiab muaj feem cuam tshuam. Piv txwv li, tsis kam ua haujlwm rau cov neeg hloov pauv lossis hais lus ntawm qee yam lus. DHCS puas tuaj yeem thov rov xav dua qhov kev xaiv CLR no lossis siv kev tiv thaiv tiv thaiv cov tswvcuab kev ntxub ntxaug?​​ 

The standard CLR Referral Status values may apply across a range of services over time. Currently, DHCS anticipates that ECM and Community Supports service providers may enter a “Declined” Referral Status for any of the following reasons: the provider lacks capacity, the Member doesn’t live in their service area, or for other reasons. MCPs should work with their Network Providers and provide clear documented procedures to determine which reasons are permissible for denying a referral in accordance with ECM and Community Supports policies and how it should be notated in the Referral Status value. DHCS is not implying that MCPs should adopt new policies to allow Network Providers to deny referrals.​​ 

Can DHCS confirm it is at the discretion of the MCP to define “CLRs that have been open for an extended period of time”?​​ 

Kev lees paub. DHCS cia siab tias qhov no yuav txawv ntawm qhov kev xav tau ntawm tus Tswv Cuab thiab hom kev pabcuam. Ib Daim Ntawv Qhia Txog Kev Siv CLR tag nrho cov xwm txheej xa mus yuav tsum tau hloov kho yam tsawg kawg ib hlis.​​ 

Can DHCS please clarify what does “respond to the inquiry” mean in the requirement “MCPs are expected to respond to the inquiry within one business day”?​​ 

MCPs are required to, at a minimum, acknowledge receipt of the inquiry and provide a status of the CLR within one business day. For example, the MCP may notify the Referring Entity or Member that a referral has been authorized and passed to the service provider for outreach on [Date] if that is the latest update the MCP has on the referral’s status. The intent of this requirement is to improve Referral partner understanding of a referral’s status more promptly, so they can also best support the Member. DHCS is not intending to issue exceptions to this requirement at this time.​​ 

DHCS yuav saib xyuas kev ua raws li qhov yuav tsum tau teb rau cov tswv cuab nug hauv ib hnub ua haujlwm li cas?​​ 

DHCS will begin conducting compliance reviews of MCPs’ CLRs one year after the implementation date of July 1, 2025. DHCS may consider requesting ad-hoc documentation, completing audits, or introducing other measures to ensure this requirement is met and will notify MCPs in advance.​​ 

Cov lus qhia meej tau thov los ntawm DHCS txog kev cia siab rau kev soj ntsuam ntsig txog Cov Tswv Cuab raug tsis lees paub rau cov kev pabcuam vim muaj kev tsim nyog. DHCS puas tuaj yeem muab qhov piv txwv meej ntawm tus txheej txheem uas ua tiav qhov kev xav tau no?​​ 

The intent of this requirement is to improve the likelihood that the need that led to the initial referral to ECM or Community Supports is still addressed for the Member. In the case of denied authorization for ECM due to eligibility, a next step for the MCP may be considering the application of CCM for the Member’s needs and offering CCM as an alternative or notifying the Member’s D-SNP of their need for care management and confirming the Member has received outreach from the D-SNP for care management support.​​ 

Most ECM referrals bypass the plan and go directly to ECM providers, who presumptively enroll Members. How can plans track the minimum data set for CLR without visibility into the referral’s origin? If tracking is required, it would add significant reporting and administrative burden to our ECM provider network.​​ 

Thov xa mus rau Cov Ntawv Ntxiv B Tshooj 1.A.3. ntawm CLR Kev Taw Qhia Txog Kev Ua Haujlwm rau kev taw qhia txog kev coding ntawm kev xa mus / kev tso cai thov los ntawm ECM Cov Chaw Pabcuam rau MCPs raws li kev tso cai tso cai.​​ 

DHCS xav kom MCPs qhia txog qib twg?​​ 

Please see the CLR Implementation Guidance section on Tracking for the full specifications and data elements that MCPs are required to track for services under CLR requirements (ECM and Community Supports). Appendix B provides additional details on values for key tracking variables such as “Referral Status” and how the data should be collected from ECM and Community Supports Providers via the monthly RTF. JSON Phase 4 templates released in February contain the detailed data elements for CLR monitoring submissions.​​ 

DHCS yuav muaj kev cuam tshuam li cas thaum cov kev xa mus tseem tseem tos rau lub sijhawm txuas ntxiv? Puas yog qhov yuav tsum tau nco txog hauv Memorandum of Understanding (MOU) nrog rau txhua lub koom haum?​​ 

Please see Section II.B.2 “Supporting Pending and Re-Referrals” of the CLR Implementation Guidance for a list of example actions MCPs can take to support ECM and Community Supports Providers in their outreach of pending referrals and recommendations for follow up with the Member and Referring Entity in these cases.​​ 

Yuav ua li cas yog tias txhua lub koom haum thov kom muaj kev cuam tshuam sib txawv los ntawm MCP (xws li, WIC hais kom ceeb toom tsis pub dhau tsib hnub ua haujlwm rau kev xa mus tseem tsis tau, Lub Chaw Haujlwm Hauv Cheeb Tsam hais kom ceeb toom hauv 30 hnub ua haujlwm, thiab lwm yam).​​ 

At this time, CLR requirements apply only to referrals made to MCPs for ECM and Community Supports. CLR Noticing requirements outline expectations for Noticing Referring Entities (e.g. CBOs, Providers, Primary Care Physicians (PCPs)) on the Referral’s Authorization Decision in accordance with timelines required in APL 21-011 and the Referral’s Closure Reason within outlined timeframes. Please see Section II.B.I of CLR Implementation Guidance for detailed MCP CLR Noticing Requirements.​​ 

Since MCPs are required to use the DHCS referral form for ECM/Community Supports, can MCPs modify this form to include ’email address’ for electronic notification purposes?​​ 

ECM Referral Standards already include “Referring Individual Email Address” as a required element in Table 2 of the ECM Referral Standards. No updates are needed to collect this information.​​ 

MCPs yuav ua li cas thiaj li muaj kev xa rov qab los ntawm tib Tus Tswv Cuab thiab rau tib qho kev pabcuam? Thov qhia ntxiv txog qhov no.​​ 

Thov saib cov piv txwv scenarios hauv qab no:​​ 

• Scenario 1: Kev xa mus rau kev pabcuam uas tus tswvcuab tau tso cai lawm. Nyob rau hauv rooj plaub uas MCP tau txais kev xa mus rau (piv txwv li, ECM) thiab tus tswv cuab twb tau txais kev tso cai qhib rau ECM, MCP yuav tsum sau cov ntaub ntawv xa mus rau qhov tseem ceeb ntawm daim ntawv xa mus (hnub, xa mus rau qhov chaw, kev pabcuam) thiab kev txiav txim siab tsim nyog (xws li, tsis kam lees) thiab muab cov ntsiab lus tsim nyog rau Lub Chaw Xa Khoom hauv Daim Ntawv Ceeb Toom ntawm Kev Txiav Txim (Cov Tswv Cuab) twb tau txiav txim siab (piv txwv li. kev ua haujlwm, qhib ECM tso cai). MCPs tseem yuav tsum muab cov ntaub ntawv tiv tauj rau Lub Chaw Xa Khoom / Tus Tswv Cuab hu rau MCP yog tias lawv xav thov kev hloov pauv hauv Tus Muab Kev Pabcuam rau lawv tam sim no, qhib kev tso cai, raws li muaj.​​ 
• Scenario 2: Referral for service for which Member has another open referral in process. The MCP should also record key CLR tracking elements on the second referral in the case that two referrals for the same service are open for the Member at the same time (e.g. date of referral, Referring Entity, service, authorization status). The MCP is still expected to fulfill CLR noticing requirements for the second Referring Entity. DHCS is requiring MCPs to record information on both referrals because MCPs still have expectations for supporting the referral through communication with the Referring Entity and for supporting any necessary coordination with the Member if the duplicate referrals generate uncertainty on the assignment of an appropriate Provider of the service. For example, if two different ECM Providers submit referrals for the Member, it will be necessary for the MCP to coordinate across the Member and Referring ECM Providers to make the Member’s preferred assignment of an ECM Provider.
  
  The MCP should follow existing policy and procedures and review the share/volume of Members that are referred by a Referring Entity and are denied authorization. If there is a high number of duplicate referrals for the same Member and same service, the MCP should facilitate a discussion and provide technical assistance with the Referring Entity to increase referrals that meet eligibility and are authorized.​​ 

CLR Daim Ntawv Qhia​​ 

If an MCP identifies an individual as eligible for ECM or Community Supports using their internal data (i.e., ‘Referral Type’ is “2. Identified by the MCP”), do noticing requirements apply?​​ 

Hauv qhov xwm txheej no, MCP yog Lub Chaw Xa Khoom thiab cov ntawv ceeb toom yuav tsis siv. Txawm li cas los xij, raws li qhov kev coj ua zoo tshaj plaws, DHCS txhawb kom MCPs qhia rau Cov Tswv Cuab tias lawv tsim nyog thiab tau raug xa mus rau ib qho kev pab cuam txhawm rau ua kom muaj feem cuam tshuam rau cov tswv cuab.​​ 

It often takes MCPs time to ingest and clean RTF data from Providers. When does the “noticing clock” of two business days for referral loop closure begin?​​ 

DHCS nkag siab tias MCPs yuav xav tau sijhawm ntxiv rau kev noj thiab ua cov ntaub ntawv thaum tau txais RTF los ntawm cov chaw muab kev pabcuam. MCPs raug tso cai ntev li tsib hnub ua haujlwm los ua cov RTF thiab ceeb toom rau Chaw Xa Mus Tsis pub dhau ob hnub ua haujlwm ntawm kev ua tiav cov ntaub ntawv (xya hnub tag nrho ntawm tau txais RTF, yog tias xav tau).​​ 

Will DHCS please confirm how the MCP is expected to proceed with noticing if the Referring Entity is the Member? The Member’s guardian or caretaker? The Member’s family, friend, or neighbor?​​ 

Nyob rau hauv rooj plaub uas ib tug tswv cuab, lawv tus neeg saib xyuas/tus neeg saib xyuas, los yog ib tug neeg hauv tsev neeg, phooj ywg, los yog cov neeg nyob ze muab xa mus thiab thov rau ECM/Community Supports kev tso cai, MCPs tseem yuav muab ntawv ceeb toom txog kev tso cai txiav txim rau tus tswv cuab. Tsis muaj lwm yam kev ceeb toom yuav tsum ua.​​ 

Qhov kev cia siab rau Cov Tswv Cuab ceeb toom yog dab tsi yog tias Ib Tug Tswv Cuab tau xaiv tsis tau txais ntawv ceeb toom los ntawm MCP?​​ 

MCPs yuav tsum ua raws li lawv txoj cai sab hauv ntawm lwm txoj hauv kev hu rau Cov Tswv Cuab nrog cov ntaub ntawv tseem ceeb lossis NOA thaum lawv tau xaiv tsis tau txais kev sib txuas lus. Piv txwv li, MCP tuaj yeem hu rau Tus Tswv Cuab hauv xov tooj lossis tso cai, kev ruaj ntseg hauv hluav taws xob yog tias lawv tau xaiv tawm ntawm kev sib txuas lus.​​ 

Puas yog Cov Tswv Cuab ceeb toom cov cai siv thaum qhov kev tso cai rau ECM raug tsis lees paub vim yog Cov Tswvcuab twb tau tso npe rau hauv ECM?​​ 

Yog lawm, txhua qhov kev xa mus rau ECM thiab Kev Txhawb Zej Zog yog ib qho kev thov kev tso cai thiab ua rau APL 21-011 ceeb toom cov cai. Raws li APL 21-011, MCPs yuav tsum siv NOA tus qauv tsim nyog uas yuav tsum muaj cov lus piav qhia luv luv ntawm cov laj thawj rau kev txiav txim siab. Nyob rau hauv rooj plaub ECM raug tsis pom zoo vim muaj kev tso cai uas twb muaj lawm, MCPs yuav tsum qhia meej txog qhov laj thawj ntawm qhov kev poob qis thiab muab ib txoj hauv kev hu rau MCP kom thov kev hloov pauv hauv lawv ECM Tus Muab Kev Pab, yog tias xav tau.​​ 

Can DHCS please clarify who constitutes as a self-referral? For example, would a neighbor or teacher be considered a self-referral for purposes of CLR noticing requirements? What is DHCS’ expectation for documenting that type of referral?​​ 

Referrals made by a Member, their neighbor, family member, friend, or guardian/caretaker are considered self-referrals. In the case of a self-referral for ECM/Community Supports authorization, MCPs must still provide notice of the authorization decision to the Member. No other noticing requirements to Referring Entities apply. MCPs must track, support and monitor all referrals made to ECM and Community Supports, including self-referrals. Teachers, in their professional capacity, serve a Member, and are not classified as a “self or caretaker referral,” therefore, are subject to noticing requirements for Referring Entities.​​ 

DHCS xav kom MCPs siv txoj hauv kev siv hluav taws xob (tsis suav nrog fax) los qhia cov ntawv ceeb toom nrog Cov Chaw Xa Mus, tshwj tsis yog lwm txoj hauv kev tsis siv hluav taws xob tau pom zoo ua ke. Qhov kev xav tau no ua rau muaj kev txhawj xeeb txog kev muaj peev xwm qhia tawm ntawm email.​​ 

Guidance on what qualifies as a secure electronic method is provided in Exhibit G of the MCP contract, the Business Associate Addendum, § 9.2. This section includes obligations related to PHI Safeguards and Security, including compliance with subpart C of 45 CFR Part 164.  DHCS recommends MCPs review the Health and Human Services (HHS) FAQ: Does the Security Rule allow for sending electronic PHI (e-PHI) in an email or over the Internet? If so, what protections must be applied?​​ 

In its answer, HHS states that “The Security Rule does not expressly prohibit the use of email for sending e-PHI. However, the standards for access control (45 CFR § 164.312(a)), integrity (45 CFR § 164.312(c)(1)), and transmission security (45 CFR § 164.312(e)(1)) require covered entities to implement policies and procedures to restrict access to, protect the integrity of, and guard against unauthorized access to e-PHI. The standard for transmission security (§ 164.312(e)) also includes addressable specifications for integrity controls and encryption. This means that the covered entity must assess its use of open networks, identify the available and appropriate means to protect e-PHI as it is transmitted, select a solution, and document the decision. The Security Rule allows for e-PHI to be sent over an electronic open network as long as it is adequately protected.”​​ 

DHCS recommends MCP’s consult with their counsel to determine secure means of electronic transmission based on this guidance from HHS.​​  

DHCS puas tuaj yeem thov qhia meej yog tias cov ntawv ceeb toom tau teev tseg hauv APL 21-011 rau cov kws kho mob (piv txwv li, MCP kom ceeb toom rau tus kws kho mob hauv 24 teev tom qab qhov kev txiav txim siab) kuj tseem siv tau rau Cov Chaw Xa Khoom raws li tau teev tseg los ntawm DHCS hauv CLR Kev Taw Qhia?​​ 

All referrals to ECM and Community Supports are an authorization request and trigger APL 21-011 noticing requirements. Under APL 21-011, MCPs must use the appropriate Notice of Action (NOA) template which must include a concise explanation of the reasons for the decision. These requirements apply for all CLRs made by Referring Entities.​​ 

Ib tsab ntawv qhia meej tau thov los ntawm DHCS kom paub meej tias MCPs tuaj yeem faib PHI, suav nrog kev mob hlwb loj (SMI) / kev siv tshuaj yeeb dawb (SUD) thiab kev noj qab haus huv rau menyuam yaus, nrog rau Cov Chaw Xa Khoom uas tsis suav nrog, yam tsis muaj kev tso cai rau tus neeg mob.​​ 

DHCS recommends indicating whether ECM or the Community Support are authorized and the reason associated with the denial as applicable. No exchange of SMI/SUD or child welfare information is necessary to share the overall service (ECM/Community Supports) and authorization decision. MCPs can also follow their existing procedures for meeting DHCS noticing requirements under APL-21-011 for ECM and Community Supports since the inception of the service in 2022. DHCS recommends MCPs consult with their legal counsel to determine whether additional details related to SMI/SUD or child welfare are necessary and can be shared via noticing under existing federal and state guidance.​​ 

Thov kev lees paub DHCS seb tsab ntawv ceeb toom CLR tshiab rau Cov Tswv Cuab yuav tsum muaj cov ntawv txuas hauv qab no: NOA, Koj Cov Cai, Lub Rooj Sib Hais Hauv Xeev, thiab daim ntawv IMR.​​ 

Kev ceeb toom rau Cov Tswv Cuab yuav tsum ua kom tau raws li cov kev cai tam sim no, tag nrho raws li APL 21-011. CLR Cov Kev Ceeb Toom Cov Tswv Cuab tsis txawv ntawm APL 21-011.​​ 

Puas yog DHCS yuav xav tau cov phiaj xwm xa cov ntawv tshiab CLR cov tswv cuab-tsim cov ntawv los tshuaj xyuas? Yog tias muaj, lub sijhawm hloov pauv yuav raug tshuaj xyuas thiab pom zoo li cas?​​ 

MCPs yuav tsum siv lawv cov ntawv ceeb toom uas twb muaj lawm rau cov kev pabcuam raug tso cai raws li APL 21-011 kom ua tau raws li cov tswvcuab ceeb toom.​​ 

Ua kom muaj kev txhawj xeeb tias ntau tus tswvcuab cov ntawv ceeb toom tuaj yeem cuam tshuam qhov cuam tshuam, ua rau muaj kev ntxhov siab ntau dua li qhov tsis meej. Tam sim no, raws li APL 21-011, Cov Tswv Cuab tau txais ib tsab ntawv thaum lawv tau txais kev pom zoo lossis tsis lees txais cov kev pabcuam ECM. Nrog CLR, lawv tuaj yeem tau txais peb lossis ntau tsab ntawv nrog NOAs, uas yuav ua rau muaj kev txhawj xeeb tsis tsim nyog.​​ 

Tsis tas li ntawd, MCPs feem ntau pom tias Cov Tswv Cuab tsis paub lawv txawm raug xa mus rau ECM thawj qhov chaw. Muaj tus kws kho mob ECM ncav cuag ua ntej NOA tsab ntawv xa tuaj yuav yog ib txoj hauv kev zoo tshaj plaws rau cov tswv cuab, kom lawv nkag siab txog kev xa mus thiab yuav xav li cas. DHCS puas tuaj yeem tshawb nrhiav txoj hauv kev los txhim kho cov txheej txheem no kom txo tau qhov tsis meej pem thiab txhim kho cov tswv cuab kev paub?​​ 

CLR Kev Taw Qhia Txog Kev Ua Haujlwm tau raug hloov kho kom muaj kev cuam tshuam tsuas yog ib daim ntawv ceeb toom xav tau rau Cov Tswv Cuab thaum lub sijhawm tso cai hauv kev ua raws li cov cai ntawm APL 21-011. ECM tau raug ua raws li APL 21-011 Kev Ceeb Toom Tus Tswv Cuab cov cai txij li nws pib xyoo 2022.​​ 

Cov piv txwv hais los ntawm Cov Tswv Cuab tsis paub txog qhov kev xa mus rau lawv sawv cev rau ECM sawv cev rau txoj hauv kev pabcuam kev pabcuam rau MCPs nrog Cov Neeg xa mus los txhim kho kev xa mus rau Chaw Ua Haujlwm ntawm kev sib tham txog kev xa mus nrog Tus Tswv Cuab ua ntej ua tiav daim ntawv xa mus raws li tau teev tseg hauv CLR Kev Taw Qhia Ua Haujlwm.​​ 

DHCS requires MCPs to use electronic methods for communicating CLR status, explicitly excluding faxes and portals. This is concerning, as the industry standard for UM prior authorization notifications relies on validated, contracted fax lines.  While we appreciate DHCS’s efforts to move away from fax communication, implementing this requirement by July 1 without the necessary technology in place presents significant challenges for MCPs in achieving compliance.​​ 

For non-contracted referring providers, we seek clarification on what qualifies as a secure electronic method, excluding fax and portal. How does DHCS define “electronic method,” and can it provide examples of secure electronic PHI sharing with entities lacking validated fax numbers or emails?​​ 

Kev taw qhia txog dab tsi tsim nyog raws li kev ruaj ntseg hluav taws xob muaj nyob rau hauv Exhibit G ntawm MCP daim ntawv cog lus, Kev Lag Luam Associate Addendum, § 9.2. Tshooj lus no suav nrog cov luag haujlwm ntsig txog PHI Kev Tiv Thaiv thiab Kev Nyab Xeeb, suav nrog kev ua raws li ntu C ntawm 45 CFR Tshooj 164. DHCS pom zoo kom MCPs sab laj nrog lawv tus kws lij choj los txiav txim siab txoj kev ruaj ntseg ntawm kev sib qhia cov ntaub ntawv hluav taws xob kom ua tau raws li CLR ceeb toom cov cai. MCPs tuaj yeem xav tshawb xyuas email ruaj ntseg lossis cov qauv zoo sib xws thiab tsim cov ntawv ceeb toom uas qhia cov ntaub ntawv tsim nyog tsawg kawg nkaus kom ua tau raws li cov kev xav tau raws li APL 21-011 thiab CLR Kev Taw Qhia.​​ 

Kev nthuav qhia tau thov los ntawm DHCS txog kev ceeb toom / kev sib txuas lus xav tau rau Cov Tswv Cuab thaum raug kaw.​​ 

DHCS pom zoo kom tsim Daim Ntawv Ceeb Toom rau Cov Tswv Cuab raug kaw hauv kev sib koom tes nrog tus neeg saib xyuas kev tso tawm ua ntej ntawm txhua lub tsev kho mob kom txiav txim siab qhov chaw nyob uas tsim nyog thiab txhais tau tias sib qhia cov ntawv ceeb toom hauv qhov tsis pub lwm tus paub uas tau txais los ntawm Tus Tswv Cuab.​​ 

Kev thov kev pabcuam (kev xa mus) raug xa mus tas li los ntawm Cov Chaw Pabcuam Hauv Zej Zog kom xa Cov Tswvcuab mus rau lawv lub koom haum rau cov kev pabcuam Community Supports. Cov neeg muab kev pab txhawb rau zej zog uas muab cov kev pabcuam yog Lub Chaw Xa Mus. Tib lub koom haum uas tau pib qhov kev xa mus yuav muab CLR hloov tshiab ntawm RTF. Hauv cov xwm txheej no, cov ntawv ceeb toom CLR puas xav tau thaum lub voj kaw? Yog tias muaj, ceeb toom rau Lub Zej Zog Kev Pabcuam / Lub Chaw Xa Xov Xwm zoo li rov ua dua thiab ntxiv lub nra hnyav rau MCP kom xa ib daim ntawv ceeb toom mus rau Lub Zej Zog Txhawb Kev Pabcuam / Lub Chaw Xa Xov Tooj uas twb paub txog kev xa mus kaw vim lawv yog tib lub koom haum uas tau ceeb toom rau MCP ntawm kev xa mus los ntawm RTF xa.​​  

Yog lawm, qhov yuav tsum tau muaj rau CLR Kev Ceeb Toom thaum Xaus Loop Kaw tseem siv tau rau hauv cov ntaub ntawv siv ntawm Lub Chaw Xa Khoom kuj yog Tus Muab Kev Pabcuam kawg. DHCS tab tom tuav qhov kev xav tau no rau cov laj thawj hauv qab no:​​ 

• Some referrals from Community Supports Providers may be for other Community Supports or may be assigned to alternative Community Supports Providers. In both these cases Referral Loop Closure notification is important for the Provider’s awareness and ongoing care coordination with the Member.​​ 

Nyob rau hauv rooj plaub uas tus xa mus raug muab tso rau hauv zej zog kev txhawb nqa thiab lub chaw xa mus kuj yog Tus Muab Kev Pabcuam, tuav cov ntawv ceeb toom rau kev xa mus kaw kaw muab cov ntaub ntawv tseem ceeb zoo rau ob qho tib si MCPs thiab Cov Chaw Pabcuam. Tsis tas li ntawd, CLR cov cai rau Kev Saib Xyuas thiab Txhawb Nqa CLRs hais txog lub luag haujlwm ntawm MCPs hauv kev tshuaj xyuas Cov Kev Xa Mus Rau Kev Xa Rov Qab Los Kaw qhov laj thawj los ntawm Tus Muab Kev Pabcuam txhawm rau txheeb xyuas qhov tsis sib xws hauv kev koom tes thiab kev coj ua zoo tshaj. Thaum kawg, CLR Cov Lus Cog Tseg rau Kev xa mus rau Loop Kaw ceeb toom tsis raug rau APL 21-011 thiab tso cai rau MCPs yooj yim hauv kev xa cov khoom, hluav taws xob ceeb toom rau xa mus rau cov koom haum uas muaj qhov ntim siab ntawm Kev xa mus kaw txhua lub hlis.​​ 

Raws li APL 21-011, MCPs tam sim no xa cov ntawv txiav txim siab tso cai rau xa mus rau cov koom haum. Nyob rau hauv rooj plaub ntawm qhov kev thov tsis kam lees txais kev pabcuam, Cov Neeg xa mus rau cov neeg xa mus twb tau txais tsab ntawv qhia lawv txog qhov tsis lees paub thiab yog vim li cas rau qhov tsis lees paub. Yog li ntawd, qhov no yuav yog qhov sib npaug kom xa daim ntawv ceeb toom kaw CLR thiab tsab ntawv txiav txim siab tso cai rau cov neeg xa mus, vim tias ob qhov kev sib txuas lus no yuav raug xa mus rau tib lub sijhawm. DHCS puas tuaj yeem hais meej yog tias MCPs yuav tsum xa cov ntawv ceeb toom CLR cais rau Cov Chaw Xa Mus Rau CLR Status: Kaw, CLR Kaw Vim Li Cas: Kev Pabcuam Auth Denied?​​  

Yog tias MCP tsis lees paub qhov kev tso cai muab kev pabcuam, ces daim ntawv tso cai ntawm kev tsis lees paub rau Lub Chaw Xa Khoom yog txaus. Yog li ntawd, nyob rau hauv cov ntaub ntawv ntawm CLR kaw vim yog ib tug tsis pom zoo kev tso cai, ib tug cais CLR ceeb toom kaw tsis tas yuav tsum tau.​​ 

Daim ntawv xa mus rau ECM​​ 

Thov qhia meej seb daim ntawv xa mus rau ECM puas yog daim ntawv thov kev tso cai vim tias tsis muaj qhov chaw nyob rau hauv daim ntawv rau ECM cov lej lossis cov chav nyob zoo.​​ 

Yog lawm, ECM Cov Qauv Kev Xa Mus Los thiab Daim Ntawv Teev Npe ua haujlwm raws li ECM xa mus rau MCPs ntawm Cov Tswv Cuab sawv cev uas ua rau muaj kev thov kev tso cai rau ECM. Thoob plaws hauv ECM Txoj Cai Qhia, DHCS piav qhia tias kev xa mus rau ECM ua rau muaj kev tso cai tshuaj xyuas sijhawm thiab ceeb toom cov cai ntawm APL 21-011.​​  

DHCS’ policy is that MCPs cannot ask community partners or ECM Providers to submit additional documentation beyond the ECM Referral Standards to make ECM authorization determinations. For example, Referring Entities are not required to provide supplemental eligibility checklists, outreach authorization forms, ICD-10 codes, proof of homelessness, Treatment Authorization Request (TAR) forms, or other extra information beyond what is specified in the ECM Referral Standards to confirm eligibility and authorize ECM (please see sections on Referrals and Authorizations in the ECM Policy Guide for details (p 107)).​​ 

Ntau qhov kev xa mus / thov kev tso cai ntawm ECM yog los ntawm cov peev txheej sab nraud ntawm ECM Cov Chaw Pabcuam lawv tus kheej, thiab DHCS tsis suav nrog cov lej tso cai lossis cov chav nyob hauv ECM Cov Qauv Kev Xa Mus. Peb nkag siab tias qee pawg MCP ECM tej zaum yuav tsum tau koom tes nrog lawv pawg UM los piav qhia cov kev xav tau tshiab thiab kho UM cov txheej txheem kom haum.​​ 

Qee qhov ntxiv, muaj feem cuam tshuam rau ECM kev tso cai thiab coding:​​ 

• Kev tso cai ECM yuav tsum muaj lub sijhawm tso cai thawj zaug ntawm 12-hli:​​ 
• (Hloov Kho Lub Xya Hli 2023) Standard ECM Daim Ntawv Tso Cai Sij Hawm: Rau txhua tus tswv cuab tau tso cai txais ECM los ntawm lawv MCP, lub sijhawm tso cai thawj zaug yuav yog 12 lub hlis thiab lub sijhawm tso cai rov qab yuav yog 6 lub hlis. MCPs yuav tsis txwv cov kev cai ntxiv rau kev tso cai ntawm ECM cov kev pab cuam dhau ntawm Cov Pej Xeem ntawm Kev Pom Zoo Kev Tsim Nyog tau teev tseg los ntawm DHCS. Piv txwv li, MCPs yuav tsis txwv kev tso cai kom txog thaum lub phiaj xwm saib xyuas tau ua tiav. (Page 108, ECM PG)​​ 
• ECM HCPCS Kev Taw Qhia - Cov lej tsim qauv rau kev thov thiab ntsib​​ 

JSON Kev Tshaj Tawm​​ 

DHCS puas tuaj yeem rov txiav txim siab thov rau ib qho JSON qhia nyob ib puag ncig CLR cov ntsiab lus kom txog thaum lub Ib Hlis Ntuj kawg 1, 2026? Nws yuav ua kom ceev faj kom txav CLR JSON qhia tawm mus rau tsawg kawg Lub Ib Hlis 1, 2026, kom tso cai rau kev siv cov txheej txheem thiab cov ntaub ntawv sib pauv kom ua tiav raws li qhov tsim nyog.​​ 

Theem 4 CLR JSON templates suav nrog cov ntaub ntawv CLR cov ntsiab lus rau kev soj ntsuam cov ntaub ntawv raug tso tawm rau MCPs thaum Lub Ob Hlis 2025 nrog rau lub sijhawm sim cuam tshuam, thiab qhov kawg Theem 4 JSON cov lus qhia tau tshaj tawm rau lub Peb Hlis 28, 2025. Tag nrho cov kev taw qhia rau kev hloov kho ECM thiab Zej Zog Txhawb Cov Ntaub Ntawv Sib Koom Cov Cuab Yeej (MIF, RTF, thiab ASF) tau tshaj tawm thaum Lub Kaum Ob Hlis 2024 nrog cov kev hloov tshiab tshwj xeeb los txhawb CLR tau teev tseg hauv cov ntaub ntawv.​​  

DHCS txhawb siab rau MCPs kom mus tom ntej nrog kev hloov kho Cov Tswv Cuab Qhia Kev Qhia Qhia kom ua raws li cov kev xav tau tshaj tawm thaum Lub Kaum Ob Hlis 2024 thiab muab kev pab cuam thiab kev txhawb nqa rau ECM thiab Cov Chaw Pabcuam Zej Zog rau Lub Xya Hli 1, 2025, mus nyob ntawm Cov Tswv Cuab Qhia Qhia Qhia Tshiab Tshiab.​​